HSV 2 - persistent itch and inflamation

[CR22]

Dear Dr.HHH

Two years ago I was diagnosed with genital HSV-2 (blood test). The only symptoms I had were fever and extreme itching of the vulva. I was also diagnosed with trichomonas and received treatment for it.

Since then, I have never had any of the typical herpes symptoms. Some times I have had perianal itching and inflammation, but no noticeable sores or blisters. Six weeks ago I started itching in my inner thighs (were the labia meet the thigh) and the outside of my labia majora. I also had the inflammation and itching of the perianal area with no visible sores. The itching occurs mostly when I'm walking or riding a bike. After 2 weeks of having these symptoms (which I thought were due to herpes) I visited a health care provider, who said the symptoms were consistent with my HSV 2 diagnosis and prescribed valacyclovir 500mg 2x a day for 5 days. It has been another 3 weeks since I finished the meds and I still have the symptoms. How likely is it that these are HSV 2 symptoms?

Since I have had the symptoms for 6 weeks, I supposed they were not due to the HSV 2 and had protected vaginal intercourse with an uninfected male partner. How likely is it that I transmitted the infection? Should he be tested even if he does not develop any symptoms?

How likely is it that I have another vaginal infection (bacterial or yeast) with no discharge or odor and just the itching? I was tested for chlamydia, gonorrhea, syphilis and HIV about 3 months ago and everything was negative.

Here are my test results from 2 years ago, please tell me if you think I need retesting (results are in spanish, I'll translate).

Test: IFA HERPES II IgG
In range: &nbsp (i don't know what this means)
Out of range: 1/500
Reference range: POSITIVE > or = 1/500

I'm currently living in the Netherlands and the STD clinic does not do serology for HSV. Do you know if I can have a proper HSV test in Europe somewhere?  I'm scared of transmitting it, as I cannot recognize the symptoms.

[H. Hunter Handsfield, M.D.]

Thanks for the feedback.  On reflection, I'm not so surprised that GGGD doesn't do type-specific HSV serology -- I disagree with that as a policy matter, but reasonable experts disagree on this.  However, I am amazed to hear that they are so cavalier about preventing sexual transmission of genital herpes.  The fact is that many (most?) people at risk for STDs, including many with HSV-2, cannot or will not consistently use condoms -- although mabye more so in NL than in the US --  and avoiding sex only when herpes lesions are present is pretty much useless advice in preventing transmission.

I'm hoping you misunderstood -- but I doubt it.  You're obviously pretty knowledgeable and articulate about these issues, so probably you are accurate conveying their policy.  Or at least the beliefs of the particular clinician you spoke with, if not of the clinic or GGGD as a whole.  They should know better!

Thanks for the thanks about the forum.  Take care.

[H. Hunter Handsfield, M.D.]

Welcome to the STD forum.  I will try to help.

I agree with your self-diagnosis that herpes is not the explanation for your symptoms, and you also are correct that the first step should be to have a proper blood test to confirm whether or not you really have HSV-2.  As you seem to know, the HSV IFA test (IFA = immunofluorescent antibody) is not reliable, because it is not type-specific; it does not accurately distinguish between HSV-1 versus HSV-2.  You might have HSV-2, HSV-1, or both.  (But you definitely are infected with one or the other.)

As you seem to understand, herpes sores can itch, but itching without sores is not a herpes symptom; and herpes certainly does not cause the sort of widespread itching you describe, i.e. labia major, upper thighs, etc.  The lack of quick response to valacyclovir also is strong evidence against herpes.  As to other explanations for your genital area itching, that's much more difficult to judge from afar.  Most STDs don't cause such widespread genital itching.  Two possibilities might be pubic lice ("crabs") or scabies (itch mite), which can be acquired sexually.

If and when you have a type-specific HSV blood test, you may find you indeed have HSV-2.  In that case, suppressive treatment with valacyclovir might be a good idea, to helpf prevent transmission to sex partners.  But even if positive for HSV-2, I still doubt it explains your current symptoms.

I am surprised to hear that a Dutch STD clinic doesn't offer type-specific HSV serology.  You might ask around, especially in the major urban centers like Rotterdam or Amsterdam.  Try calling GGGD (I forget what the initials mean, but it's the main health department in Amsterdam) and asking about it.  Or see a private health care provider.  If you travel to UK from time to time, you certainly can find testing available at a National Health Service Genitourinary Medicine (GUM) clinic.

I hope this helps. Best wishes--  HHH, MD

[CR22]

Thanks for the quick response. I actually got tested for STDs in the GGGD in Amsterdam, and in the moment I asked for HSV serology, and the doctor said they did not do it because many people have antibodies. They only do testing via culture of lesions. I also went to the doctor of the UvA, and got the same response. Apparently, HSV2 is also very common here, and doctors don't seem too worried about it, they just told me to use condoms and not have sex if I had lesions. I also believe that HSV doesnt have the same social stigma as in the US and/or people don´t even know about it.
I guess my only choice is to go to a private doctor.
Thanks again for your answer. I have learned a lot through this forum.
Best regards.

[H. Hunter Handsfield, M.D.]

I saw this comment before I responded above.  It doesn't change my opinion or advice.

[CR22]

I forgot to write that that blood test was done 2 and a half months after the exposure and that the symptoms appeared like a week after the exposure, but in the moment were not diagnosed as HSV 2 by a health care provider and cleared in a week or so. The blood test was done later because I started a new reationship and wanted to be sure I did't have anything.